<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920141
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:22:09 PM


Document Has Been Signed on 08/14/2024 01:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SPLENDOR OF CARMICHAEL AT PALM, LLC, THEFACILITY NUMBER:
345920141
ADMINISTRATOR:VO, LUIGIFACILITY TYPE:
740
ADDRESS:2839 CALIFORNIA AVE.TELEPHONE:
(916) 550-2908
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Luigi Vo, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Hood met with Administrator, Luigi Vo, to conduct a Pre- Licensing visit. This application is a change in ownership. This address is currently licensed as THE SPLENDOR OF CARMICHAEL AT PALM Facility #: 342700535. The facility has a fire clearance for six (6) non-ambulatory residents. Facility is approved for a hospice waiver for three (3) residents. Administrator has an active certificate (#6067873740 with expiration date 11/3/2026).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and seven (7) bathrooms for resident use. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 114.6 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA reviewed five (5) resident files and two (2) staff files.

Component III was waived. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1